Ophthalmology and Optometry Coding Alert

Question: What is proper diagnosis coding if a patient comes in with a foreign-body sensation and an exam shows no sign of a foreign body or irritating substance?

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Answer: Although many physicians feel the need to provide a definitive diagnosis when submitting a claim, there are many circumstances in which the symptom the patient presented with is the only thing they can find. Proper diagnosis coding requires you to code the complaint that put the patient into your chair, not necessarily what the ophthalmologist ultimately found.

Do this: Review the patient’s chart thoroughly. If you find that the patient has dry-eye syndrome, for example, that is a possible cause of foreign-body sensation. In that case, you would use an ICD-10 diagnosis code such as:

• H04.121 – Dry eye syndrome of right lacrimal gland
• H04.122 – ...of left lacrimal gland
• H04.123 – ...of bilateral lacrimal glands
• H04.129 – ...of unspecified lacrimal gland
• H16.221 –Keratoconjunctivitis sicca, not specified as Sjögren’s, right eye
• H16.222 –...left eye
• H16.223 –...bilateral
• H16.229 – ...unspecified eye.

If it is a foreign-body complaint, chances are the patient is in some kind of pain, and if the pain cannot be attributed to something specific – an eyelash, for example, H02.05x (Trichiasis without entropion) – you have the option of using an unspecified eye-pain code, such as H57.1x (Ocular pain) or a code representing a specific result of the pain.

For example, if the foreign-body sensation resulted in inflammation, you can report S05.00XA-S05.02XA (Injury of conjunctiva and corneal abrasion without foreign body…).